interventions in the management of concussions anne felicia ambrose m.d., m.s., fabpmr medical...

Interventions in the Interventions in the Management of Management of ConcussionsConcussions

Anne Felicia Ambrose M.D., M.S., FABPMRAnne Felicia Ambrose M.D., M.S., FABPMRMedical Director , Traumatic Brain Injury ProgramMedical Director , Traumatic Brain Injury Program

Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai New York, NYNew York, NY

Department of Emergency Medicine

Approach to the Management of Concussion

1. Pre-Injury1. Create and Implement legal safeguard at state, national, Sporting

Body level2. Changes to the Game-Rules of Play3. Protective equipment; 4. Pre-injury assessments

2. Injury1. Assessments-On the sidelines, ED, Doctor’s Office- Screening,

Imaging

3. Post Injury Interventions1. Rest2. Return to Play Protocol3. Physical and Occupational Therapy4. Cognitive and Behavioral Assessments and Therapy5. Vision Therapy6. Vestibular Therapy7. Drug Therapy8. Retirement

Department of Rehabilitation Medicine

Features of sport-related concussion

SYMPTOMS/PHYSICAL SIGNS

SLEEP DISTURBANCES

COGNITIVE IMPAIRMENT

EMOTIONAL/ BEHAVIOURAL CHANGES

Loss of consciousnessHeadacheNausea/VomitingDizzinessLoss of balance/poor coordinationVisual disturbancesPhotophobiaAmnesiaDecreased playing ability

DrowsinessTrouble falling asleepSleeping more than usualSleeping less than usual

Slowed reaction timesDifficulty concentratingDifficulty rememberingConfusionFeeling in a fogFeeling dazed

IrritabilityEmotional labilitySadnessAnxietyInappropriate emotions

Basic Principles-Post Injury Interventions

1. Rest-Physical and cognitive rest until

asymptomatic

2. Graded program of exertion

3. Additional Evaluations and Interventions

4. Medical clearance

5. Return to play.

Department of Rehabilitation Medicine

Rest-Physical and Cognitive

1. Collegiate and High School students athletes who RTP on

the same day have poorer outcomesNeuropsychological deficits post-injury that may not be evident on the

sidelines and are more likely to have delayed onset of symptoms..

2. Malignant brain edema syndrome-seen rarely, but almost

exclusively in young athletes

3. Second Impact Syndrome

4. Young (<18) elite athlete should be treated more

conservatively even though the resources may be the same

as an older professional athlete

Department of Rehabilitation Medicine

Fatigue and Sleep

1. Incidence

2. Clinical features

3. Associative factors-Pain, Pain meds, Females, Depression, Anxiety, time from injury

4. Association with cognition-slower in attentional tasks

5. Sleep disturbances-Drowsiness. Trouble falling asleep, Insomnia, Hypersomnia

6. Treatment

Headaches

Investigation

CT scans be helpful in ruling out serious bleeding injuries, but cannot

diagnose a concussion or headache.

Treatment

1.Rest, Avoid second concussion especially in first 10 days

2.Medications

a. No medicine that clearly alleviates post concussive headache.

b. Regular headache medications may help.

c. Preventive medications if not resolved within a month. (SE-increase fatigue,

weight, or memory, confusion) especially in athletes with long playing history, prior

+/- recent concussions, Apo E

Cognitive Impairment

1. Incidence

2. Clinical Features-Slowed reaction times, Difficulty concentrating and

remembering, Confusion, Feeling in a fog or dazed

3. Cognitive RestructuringForm of brief psychological counseling that consists

of education, reassurance, and reattribution of symptoms

4. Cognitive And Behavioral Assessments and Remediations

Visual Deficits

Department of Rehabilitation Medicine

Approach to Common Vision Deficits Following TBI

Department of Rehabilitation Medicine

Deficit Primary Associated Symptom: Treatment

Accommodation Constant/intermittent blur Lenses, restorative accommodation training

Tear Film Integrity

Distorted clarity/gritty sensation, which varies with blinking

Eye drops

Versional Ocular Motility

Slower, less accurate reading /difficulty sustaining gaze, shifting gaze, or tracking targets

Basic scanning and searching exercises Typoscopic approach

Vergence Ocular Motility

Constant/intermittent eyestrain / diplopia eliminated with monocular occlusion

Fusional prism,;Varying degrees of occlusion ; Vergence stabilizing exercises

Approach to Common Vision Deficits Following TBI

Deficit Primary Associated Symptom: Treatment

Visual-Vestibular Interaction

Disequilibrium exacerbated in multiply, visually-stimulating environments

Adaptive exercises using graded provocations.correct accommodation

Light-Dark Adaptation

Elevated light sensitivity Tinted lenses

Visual Field Integrity

Missing a portion of vision Yoked or spotted prisms, mirrors, and field expanding lenses ,scanning strategies and compensatory/ adaptation approaches

Visual processing

Slower speed/impaired visual memory and visual-spatial processing

Adaptive and restorative exercises

Nausea/Dizziness/Vertigo/Loss of BalanceCauses of dizziness, Impaired balance or vertigo

1. Benign paroxysmal positional vertigo (BPPV),

2. Labyrinthine concussion,

3. Perilymphatic fistula (PLF),

4. Post-traumatic Meniere Syndrome (hydrops),

5. Temporal bone fracture,

6. Cervical (cervicogenic) vertigo,

7. Epileptic vertigo,

8. Migraine associated vertigo and ocular motor abnormalities.

Department of Rehabilitation Medicine

Symptoms of Post-concussive Vestibular And Balance Dysfunction

1. Dizziness (55–78%),

2. Impaired Balance (43–56%),

3. Blurred Vision Or Diplopia (49%)

(Lovell, 2009).

Department of Rehabilitation Medicine

Approach to Treatment of Vestibular Dysfunction

1. Rest

2. Evaluation if symptoms persist >2 weeks

3. Medications-avoid meclizine, Aspirin

4. Assessments1. Detailed history of concussion occurred,2. Initial presenting symptoms, 3. New or existing medications, 4. Prior history of concussions, or any past imaging or treatment.5. Clinical diagnostic tools are used to determine the severity of the symptoms

to identify potential structural lesions. 1. Balance Error Scoring System (BESS) test, 2. computerized dynamic posturography (CDP) which includes balance tests, the

Sensory Organization Test, and visual tracking technologies

(Lovell, 2009)

Type and purpose Theoretical description Example

Canalith repositioning maneuver(Curative for BPPV)

Diagnostic and therapeutic maneuvers simple and effective for BPPV

Repetitive head movements

Habituation(For impaired motion sensitivity)

Provocation of stimuli induces symptoms; enhances vestibular compensation; requires repetition; intensity of exercise proportional to severity of symptoms

Head position or movement inducingdizziness or vertigo

Adaptation(For impairments in convergence)

Enhancement of intact vestibular circuits to compensate for loss of function within same system; Use of retinal slip during head movement(verticle or horizontal)

Instructed to move head while maintaining focus on moving (VOR1) or stationary(VOR2) target. Degree of difficulty of exercise increased progressively

Type and purpose Theoretical description

Example

Substitution(For major vestibularimpairment)

Replacement of deficient vestibular system byenhancement of ocular systems

Exercises that facilitate preprogrammed eyemovements to scan field and detect targetin order to prompt head and neckmovements to override vestibular-ocularreflex

Balance exercises(To enhance supportive balancesystems)

Positional Exercises

Proprioceptive Neuromuscular Facilitation

Static balance= alternating visual and somatosensory input, with change of support base-> Wide vs Narrow

Dynamic balance= higher level of challenge. Head turning while walking; quick head turn (right or left) while walking; incorporating task while walking-> tossing an object or cognitive task while walking

Aerobic exercise(To strengthen balance viamuscle conditioning)

Promotes strengthening of muscle groups to helpimprove balance reaction time

Progressive walking exercise with increasetime and intensity. Advance gradually tosustained aerobic activity.

Pharmacological therapy in sports concussion

1. Role of pharmacological approach 1. Management of specific prolonged symptoms (e.g. sleep disturbance,

anxiety etc..).2. Modify the underlying pathophysiology of the condition with the aim of

shortening the duration of the concussion symptoms.

2. An important consideration in RTP is that concussed athletes should not

only be symptom free but also should not be taking any pharmacological

agents/medications that may mask or modify the symptoms of

concussion.

3. Where antidepressant therapy may be commenced during the

management of a concussion, the decision to return to play while still on

such medication must be considered carefully by the treating clinician.

Department of Rehabilitation Medicine

Retirement

1. Professional athletes with a history of multiple

concussions and subjective persistent neurobehavioral

impairments

2. Counseling. about the risk factors for developing

permanent or lasting neurobehavioral or cognitive

impairments and should recommend retirement from

the contact sport to minimize risk for and severity of

chronic neurobehavioral impairments

Department of Rehabilitation Medicine

Play Safe Program at Mount Sinai

anne.ambrose@mssm.edu

Department of Rehabilitation Medicine